Scoring Tools
This 10 item clinician administered scale is the most commonly used tool to assess alcohol withdrawal severity, though it was originally designed for research and requires the patient to answer questions.
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol–Revised)
Per the ASAM guideline, this class of medications is the first-line treatment for moderate and severe alcohol withdrawal due to their known effectiveness in preventing seizures and delirium.
Benzodiazepines
Signs and symptoms of alcohol withdrawal typically begin within this time frame after cessation of or reduction in alcohol use.
6-24 hours
Per the ASAM guideline, this B-vitamin should be provided to ALL patients undergoing alcohol withdrawal to prevent a potentially devastating neurological complication, with typical dosing of 100 mg IV/IM per day for 3–5 days.
Thiamine
Alcohol increases the inhibitory effects of this major inhibitory neurotransmitter's receptor while suppressing the brain's major excitatory neurotransmitter, glutamate, at the NMDA receptor.
GABA
Unlike the CIWA-Ar, this scoring tool does NOT require the patient to answer questions and instead assesses pulse, blood pressure, tremor, sweating, hallucinations, agitation, orientation, delusions, and seizures - making it ideal for ICU patients who may be intubated.
mMINDS (modified Minnesota Detoxification Scale)
The ASAM guideline identifies this as the preferred benzodiazepine dosing method, as it reduces duration of treatment and length of stay compared to fixed-dose schedules.
Symptom-triggered dosing
This most serious manifestation of alcohol withdrawal is characterized by severe confusion, disorientation, hallucinations, and severe autonomic hyperactivity, with onset typically between 72 and 96 hours after the last drink.
Delirium Tremens (DT)
Wernicke encephalopathy classically presents with a triad of encephalopathy, ataxia, and this third finding — though the full triad is seen in fewer than one-third of cases.
ocular abnormalities (nystagmus)
This medication works by binding to GABA-A receptors and increasing the frequency of chloride channel opening, which enhances the effect of GABA.
Benzodiazepines
In a prospective study of 66 assessments by 49 ICU nurses, this tool was rated easiest to use (mean score 2.9/9) and was preferred by 69.7% of respondents over both CIWA-Ar and SEWS.
mMinds
This medication has been used for alcohol withdrawal since the 1920s, provides both GABA-A agonism and glutamate antagonism, and the ASAM recommends it as a first-line alternative when prescribed by experienced practitioners.
Phenobarbital
Alcohol withdrawal seizures may begin as early as 8 hours after cessation and can continue for up to 48 hours, with peak activity occurring around this time point.
24 hours
T/F
You should give thiamine before glucose
Sudden cessation of alcohol triggers an acute neurotransmitter imbalance with a rapid decline in inhibitory GABA activity and increased activity at this excitatory receptor, resulting in overall CNS hyperactivity and a lower seizure threshold.
NMDA receptor
The SEWS scale assesses five domains: blood pressure, heart rate, temperature, tremor, and this fifth domain that evaluates the patient's mental status and level of consciousness
Orientation/mentation
Per the ASAM guideline, this anticonvulsant could be an appropriate monotherapy alternative to benzodiazepines for mild-to-moderate withdrawal in low-risk patients. Diabetic patients also use this medication.
Gabapentin
According to the DSM-5, at least this many of the listed criteria: autonomic hyperactivity, tremor, insomnia, nausea/vomiting, hallucinations, psychomotor agitation, anxiety, or seizures must be present to diagnose alcohol withdrawal.
2
Per the ASAM guideline, phosphorus supplementation is required when the serum level falls below this threshold.
<1 mg/dL
This phenomenon, first described by Ballenger & Post in 1978, proposes that repeated episodes of alcohol withdrawal lead to progressively more severe subsequent withdrawal episodes, including increased seizure susceptibility.
Kindling
A key advantage shared by both SEWS and mMINDS over the CIWA-Ar is that neither tool requires the patient to do this, making them more practical for sedated, intubated, or severely altered patients.
Verbally Respond
For patients with advanced liver disease, this shorter-acting benzodiazepines are preferred because it lacks active metabolites and have less hepatic metabolism.
Lorazepam
Approximately this percentage of individuals with a history of long-term heavy alcohol consumption will experience some degree of mild withdrawal when alcohol use is stopped, while only 3–5% of hospitalized withdrawal patients develop delirium tremens.
50%
A 2016 critical care review recommended abandoning the traditional "banana bag" for ICU patients with alcohol use disorder and instead using this three-component regimen: 200–500 mg IV thiamine every 8 hours, approximately 4–5 g magnesium sulfate, and 400–1,000 μg IV of this vitamin whose deficiency causes hyperhomocysteinemia and macrocytic anemia.
Folic acid
Phenobarbital is considered pharmacologically well-suited for alcohol withdrawal because it addresses BOTH dominant aspects of AWS pathophysiology: it increases the duration of GABA-A channel opening AND has direct blockade effects on this excitatory neurotransmitter system
Glutamate